Penile Prosthesis Implantation

Penile Prosthesis Implantation
Fried Symposium
2016
Culley C. Carson III, MD, FACS, FRCS(hon)
University of North Carolina
Chapel Hill, N.C.

Management of ED
All Patients
Sexual/
Medical History
Physical Exam
Discuss Options
Laboratory Tests
Noninvasive Tx
(Oral, VED, MUSE, PEP)
Additional Tests
(NPT, Doppler, DICC)
Surgical/Invasive Tx
**

Penile Prosthesis History
• Bogaras(1936)-Rib
cartilage
• Frumkin(1943)-Rib
cartilage
• Scardino (1950)-
Acrylic stent
• Goodwin &
Scott(1952)-Acrylic
stent
• Lash(1964)-Silicone
implant
• Pearman(1967)-
Trimable silicone
implant
• Morales(1973)-
Intracavernosal
implant
• Small &
Carrion(1973)-
Intracavernosal
implant
• Scott(1973)-Inflatable
implant

Types of Prostheses
• Malleable/semirigid
– AMS, Coloplast, Jonas
• Mechanical rod
– AMS Dura II
• Inflatable
– 2-piece – AMS Ambicor
– 3-piece –
• AMS 700 (CX, CXR, LGX)
• Coloplast (Alpha-1, Titan, Narrow Base)

Penile Prosthesis Modifications
• Single tubing connectors
• Lock-out valve in fluid reservoir or pump to
prevent autoinflation
• Parylene Coating
• Pump Improvements
– MS (AMS)
– OTR (Coloplast)
• Prevention of infections
– Antibiotic-impregnated coating
(InhibiZone , AMS)
– Hydrophilic/anti-adherence surface (Titan,
Mentor)

Penile Implant Indications
• Oral drug (PDE5 inhibitor) failure
• Radical Prostatectomy
• Diabetes mellitus
• Cardiovascular
• Scarred penis
– Priapism
– Previous implant
– Trauma
• Peyronie’s disease
• Severe venous leak

Issues Regarding Informed Consent
• Size of penis—usually slight loss in penile length
• Possible need for revision surgery
– Infection
– Malfunction
– Tissue damage
• Sensation
• Ejaculation
• Discuss alternative treatments, eg, vacuum
constriction device (VCD), Medicated Urethral
System for Erections (MUSE), Pharmacologic
Erection Program (PEP), etc
• Variety of prostheses
• Reduced erectile function if device removed

Reliability—Device Survival
Milbank pre1992 Ultrex 78% 5 years
Levine Ambicor 93% 3-5 years
Choi CXM 90% 5 years
Carson CX 86% 5 years
Montorsi AMS700 96% 5 years
Wilson Mentor Alpha-1 93% 5 years
Govier 3 Piece Impant 91% 3 years
Dubocq Mentor 96% 5 years
AMS 84% 5 years

Patient/Partner Satisfaction
Patient
Partner
Carson
Levine
93%
96% 91%
Montorsi 98% 96%
Chiang (Taiwan Series) 87% 71%
Montorsi (Peyronie’s) 79% 75%

Satisfaction Questions
• “Would you undergo the procedure again?”
– Yes: 154 (86.5%)
– No: 20 (11.2)
– Not sure: 4 (2.2)
• “Would you recommend implant surgery to a
friend?”
– Yes: 157 (88.2%)
– No: 19 (10.7)
– Not sure: 2 (1.1)
Carson et al J. Urol 2000

Reasons for Dissatisfaction With
Penile Implant
• Loss of penile length
• Loss of sensation
• Mechanical malfunction
• Reduced sexual
spontaneity
• Unrealistic expectations
• Cost

Post IPP Length
E. Osterberg et al IJIR 2014

Penile Prosthesis
Pros
• High patient satisfaction rate
• 7 to 10 years average functional prosthesis life
• Higher spontaneity than medications
• Discreet, normal appearance
• Erection longevity controllable
• Significant clinical data on procedure and results
• Erection hard enough for penetration, allowing
patient to complete sexual intercourse

Penile Prosthesis
Cons
• Potential for infection, device malfunction
• Major surgery
• Postoperative pain
• Irreversible
• Additional surgery at product end-of-life
• Potential decreased sensation, glans sensitivity,
ability to ejaculate/reach orgasm
• Complications : infection, device malfunction
with replacement/salvage surgical procedure
• Cost/ insurance reimbursement

Implant Surgical Technique
• Infrapubic approach
– Familiar surgical approach for urologists
– Easy placement of reservoir
– Potential injury to dorsal penile nerve
• Penoscrotal approach
– Easy dissection and corporal dilation
– Penile nerves not in surgical field
– Blind placement of reservoir sometimes
difficult

AMS 700 CX: Surgical Approach
Approach Frequency %
Penoscrotal 161 43.3
Infrapubic 204 54.8
Unknown 7 1.9
Carson et al J. Urol 2000

Challenging Problems with Penile Implants
• Distal cylinder erosion
• SST deformity
• Proximal cylinder erosion
• Severe Corpus cavernosum
fibrosis
• Implant Infection

Difficulty dilating corpora
•Fibrotic Corpora due to
• Peyronie’s Disease
• Priapism
• Pharmacologic Erections
• Secondary Implant
• Trauma
• Infection

What do you do if have a fibrotic corpora?
•Virgin Corporotomy site
•Mid/distal corporal incision
•Multiple corporotomies
•Excise fibrotic core
Urethratome
Corporal resection
•Use a single cylinder
•Cavernosal Reconstruction
•Narrow Base Cylinders

Corporal Fibrosis
Instruments
•Metzenbaum scissors
•Curved and straight Mayo scissors
•Large Kelly Clamp
•Brooks dilators
•Hegar dilators 8 – 16mm
•Dilamezinsert instrument
•Rossello Cavernotomes
•Otis Urethrotome

Corporal Fibrosis
•Options to consider
• Have all instrument available at outset
• Resection of fibrous cavernosal tissue
• Additional Distal corporotomy
• SIS/Tutoplast graft
• Windsock (Goretex/Dacron)
• RTE suture

Corporeal Perforation
•Can occur distal, proximal,
lateral
•What do you do?
•Wind sock (Gortex, Dacron,
Tissue)
•Repair Corpora
•Suture in rear tip

Proximal Perforation
•Weak Tunica proximally
•Surgeon perforates near
crus

Distal (corporal and urethral)
Perforation
•Occurs during dilation of corpora
•Fix with distal corporoplasty
•Single cylinder implantation (plug)
•Allow urethral perforation to heal
over catheter and re-operate 2+
months
•May place NB cylinders if due to
fibrosis

Cylinder/Pump Erosion
•Due to urethral catheters
•Decreased penile sensation
•Irradiation
•Cortisone
•Urethral strictures
•Previous erosion
•Infection

Infection
Incidence
• 1-3% - Primary procedures
• Up to 10% - Secondary procedures
• How (Signs and symptoms)
– Persistent pain
– Fixation of pump
– Purulent drainage
– Exposed foreign body
• Rarely
– Fever

• ½ Strength Betadine
• ½ Strength Hydrogen Peroxide
• Antibiotics Vancomycin +
Salvage Irrigations
• Antibiotics – Vancomycin +
Gentamicin
• ½ Strength Hydrogen Peroxide
• ½ Strength Betadine
• Pressure Wash with Vancomycin-
Gentamicin Solution

Summary: Penile Implant Surgery
• Available (malleable and inflatable types) less than 40
years
• For men who fail less invasive ED treatment
• Relatively expensive and invasive
• Provide the highest rate of long-term satisfaction for
patients and partners of all ED treatments
• Recent product modifications provide higher patient
success, satisfaction and longevity rates
• Surgical implantation of penile implants for severe ED
likely to remain in urologist’s treatment
armamentarium